Executive Summary

Introduction

The National Institute of Neurological Disorders and Stroke (NINDS), National Heart, Lung, and Blood Institute (NHLBI), and
National Institute on Aging (NIA) sponsored a two-day workshop titled Preventing Stroke and Heart Disease: Connecting Traditional and Emerging Approaches to Change Behavior on November 12 and 13, 2009. The purpose of the workshop was to identify strategies and approaches for strengthening community
education and outreach aimed at reducing the risk for stroke and heart disease. A key goal was to arrive at a set of recommendations
for how current and future efforts can be more successful in prompting and supporting relevant health seeking and risk-reducing
behaviors.

Foster consideration of non-traditional, new, and emerging innovations that hold promise of strengthening and extending the
reach and impact of community education;

Identify gaps and unmet needs in relevant research and evaluation, with a focus on what remains to be done and how it can
be done better; and

Recommend strategies and approaches for enhancing the effectiveness of current and future programs and interventions.

The workshop was chaired by Walter J. Koroshetz, M.D., Deputy Director, NINDS and Lawton Cooper, M.D., M.P.H., Health Scientist
Administrator, NHLBI. Participants included representatives from public health, community organizations, the academic and
research community, communications and marketing, information technology, and patient and professional organizations.

The first day of the workshop was devoted to presentations that highlighted lessons learned from traditional approaches to
community education, outreach interventions, and communications campaigns; examined gaps and unmet needs in public health
approaches; and considered new and emerging communication tools and innovations for use in future public health campaigns.
Presentations were divided among four panel areas:

Opening Sessions

The opening sessions focused on overarching successes, lessons learned, and challenges in realizing awareness and behavior
change through public health and marketing initiatives, in addition to well-known, large-scale cardiovascular disease prevention
programs.

Panel 1: Key Elements That Have Driven Success and Behavior Change highlighted the cross-cutting best practices and program elements in controlled or quasi-experimental programs and mass communication
campaigns that have proven effective. Panel speakers addressed key elements that have driven success or behavior change in
various highlighted programs, such as community involvement and mobilization, policy and environmental changes, and widespread
exposure to messages.

Panel 2: Unmet Needs in Community Education and Prevention highlighted key areas of program planning, implementation, or evaluation in various kinds of campaigns that require more
application or research.

Panel 3: Insights from Priority and Underserved Communities identified common elements for success in audience-centric programs and campaigns (regardless of the audience), as well as
audience-specific tactics that have proven successful. The panel also discussed areas that need further focus and examination,
such as effectively addressing barriers to preventive care and building community support.

Panel 4: New and Emerging Opportunities and Innovations focused on identifying new or promising ways of prompting and supporting behavior change. Speaker presentations addressed
how current and emerging technologies, new digital communication patterns, behavioral economics, and commercial marketing/advertising
strategies can help change the way people learn about and make relevant health decisions.

The second day of the workshop brought together small workgroups to distill content from Day 1 and advance recommendations
for improving and expanding future community education programs about stroke and heart disease. Workgroups focused on policy
and environmental level efforts for community change, impact of communications technology on change, designing evaluation
for realistic and valid outcomes, and building community support and capacity for prevention programs.

Recommendations that emerged from participants throughout the workshop included:

Cultivate public-private partnerships and increase collaboration with government, community, policy, industry, and academic
organizations. Participants recognized the power of partnerships in broadening access to information and resources, eliminating overlap
of efforts, and reaching all segments of society that are essential for affecting and sustaining change. In addition, they
recognized that societal change can occur when all “market forces”—including public and private entities—are leaning in the
same direction.

Recommendations for increasing and best utilizing collaborations among groups in all sectors included:

Embracing non-traditional and new partnerships among government, nonprofit, and corporate entities and building on existing
collaborations and coalitions;

Building a base of resources, expertise, and support among an array of organizations that offer credibility, expertise, and
channels for dissemination of health messages; and

Engaging leaders at national and community levels who can serve as trusted messengers of health information.

Focus on policy and environmental change for broader social change. In order to create a prevention culture, participants agreed that public health professionals need to focus both on environmental
and individual change. Public policy changes provide the “push” that creates an environment receptive to healthy behaviors
while individual interventions provide the “pull” that leads to individual behavior change. Panelists concluded that while
people and places are inextricably linked, public health professionals are just beginning to recognize the significant influence
of place on behavior change. Public health coalitions, collaboratives, and consortia are working at influencing the way
people live by changing community design and focusing on policy, environmental, and systems changes—for better food, promoting
fitness, access to care, and to turn the health paradigm from illness to wellness.

Recommendations included:

Focusing on legislative efforts (e.g., taxes on tobacco, bans on soda machines and fast food in public schools); local zoning
changes (e.g., to include more parks, sidewalks, green spaces, and bike trails to promote exercise); and building incentives
(e.g., to attract farmers markets and grocery stores into “nutritional deserts,” or health care into rural areas or urban
neighborhoods);

Developing a policy development toolkit to help partners navigate the policy environment, advocate for changes, and promote
activities to prevent CVD and stroke; and

Supporting employee health and wellness policies that advance a more comprehensive approach to behavior change.

Engage priority and underserved communities. Participants focused on two major areas for better serving priority and underserved communities—addressing engagement, and
health equity. Engagement is a commitment to obtaining community involvement in developing and conducting interventions from
planning and implementation to evaluation. Creating health equity involves establishing a level playing field by examining
what causes health inequity (e.g., myths, biases, culture, language, and late adoption) and the importance of the role of
place, community, and neighborhood in change.

Engaging in conversation with the community to identify beliefs, biases and health literacy to ensure message comprehension
and culturally sensitive content;

Identifying familiar and non-intimidating environments in the community to deliver messages (e.g., churches, community centers,
family reunions, health fairs, and screenings) that require little or no expenditure of limited individual and community
resources; and

Training community change agents to conduct or assist in public health interventions as community health workers.

Engage resources from multiple sources, including foundations, health maintenance organizations, professional societies and
corporations. The logistical and systemic challenge of sustaining programs was a key issue raised throughout the workshop. Participants
suggested that program planners seek funding and commitment from a variety of sources to extend the length of time and types
of activities that can be covered. An effective program of behavior change that improves health outcomes should fit the mission
of a large number of stakeholders.

Recommendations included:

Seeking funding from multiple organizations that align with particular elements or phases of a program—such as planning, mass
media outreach, and social media implementation;

Establishing larger partnerships with these organizations so that additional significant activities may be pursued together,
such as lobbying for environmental changes and embarking on larger community-wide research studies; and

Distinguishing program costs to provide a more accurate picture of funds needed to develop , implement and sustain a behavior
change program.

Harness the power of new and emerging communication tools. Participants recommended that health professionals embrace “Web 2.0” technologies that focus on focus on engagement, online
communities, collaboration, user-generated content, and new and innovative applications to efficiently and effectively communicate
health messages about stroke and heart disease. They agreed, however, that the use and messages communicated in these ways
should be highly tailored to meet the needs, interests, and social media habits of key audiences. They also agreed that new
media technologies should not take the place of traditional forms of communication, but should augment them and provide additional
channels for reaching audiences with the tools already in use.

Recommendations included:

Focusing on the quality of messages and dialogue using new media rather than on the quantity;

Considering the use of mobile phone interventions that are widely used by underserved audiences; and

Applying resources to accurately evaluate the reach and impact of new and emerging technologies.

Develop more effective evaluation measures. Focus should be on identifying and examining specific elements of an intervention, as well as understanding which elements
are succeeding in motivating audiences to change their behaviors. Evaluation activities should be conducted and measurements
should be taken at more regular intervals rather than just at the start and end of a campaign. Finally, participants agreed
that a new layer of evaluation should be included to study and better understand the effectiveness of policy and environmental
changes in prompting better personal health choices and leading to greater overall health outcomes.

Recommendations included:

Designing evaluation with established theories of learning in mind;

Allowing different elements (e.g., one-on-one interventions and mass media) to be unpacked and examined to identify those
that can be discarded, modified, or retained; and

Assessing actual behavior change rather than knowledge alone to provide a more accurate view of the effectiveness of an intervention.
Participants agreed that measuring knowledge, awareness, and intention are poor proxies for behavior change